One-stage Soave pull-through for Hirschsprung's disease: A comparison of the transanal and open approaches

doi:10.1053/jpsu.2000.6849

Journal of Pediatric Surgery

Volume 35, Issue 6, June 2000, Pages 820-822

Presented at the 1999 Annual Meeting of the Section on Surgery of the American Academy of Pediatrics, Washington, DC, October 8-10, 1999.

https://doi.org/10.1053/jpsu.2000.6849 Get rights and content

Abstract

Purpose: The authors reviewed their experience using the transanal Soave technique, to determine (1) if it offers any advantages over the standard open approach and (2) whether routine laparoscopic visualization is necessary. Methods: The case reports of 37 consecutive children less than 3 years old undergoing Soave pull-through were reviewed. Patients were excluded from analysis if they had total colon disease or had a previous colostomy. The patients were divided into 3 groups: open Soave (OS, n = 13), transanal Soave with routine laparoscopic visualization (LVS, n = 9), and transanal Soave with selective laparoscopy or minilaparotomy (TAS, n = 15). Cost was calculated based on hospital stay, operating room time, and use of laparoscopic equipment. Results: In the TAS group, suspicion of a longer segment led to the selective use of laparoscopy with or without biopsy in 2 children, and the use of a small umbilical incision for mobilization of the splenic flexure in 2. There were no differences among groups with respect to age, weight, gender, transition zone, operating time, blood loss, intraoperative complications, enterocolitis, or stricture or cuff narrowing. Hospital stay was significantly longer in the OS group (median, 7 days; range, 3 to 47) than the LVS (median, 1; range 1 to 6) or TAS (median, 1, range, 1 to 3) groups. Cost (in thousands of dollars) was also higher in the OS group (median, 6.9; range, 3.9-25.7) than the LVS (median, 3.9; range, 3.6 to 6.4) or TAS (median, 3.4; range, 2.2 to 9.4) groups. Repeat surgery was necessary for 4 OS patients: 2 adhesive small bowel obstructions (1 of whom died), 1 twisted pull-through, and 1 recurrent aganglionosis. Three TAS patients required repeat surgery: 1 twisted pull-through, 1 anastomotic leak, and 1 cuff narrowing. Conclusions: These data suggest that the transanal pull-through is associated with a significantly shorter hospital stay and lower cost than the open approach, without an increased risk of complications. Because there is no intraabdominal dissection, there probably is a lower incidence of adhesive bowel obstruction. Routine laparoscopic visualization or minilaparotomy is not necessary but should be used in children who are at higher risk for long segment disease. J Pediatr Surg 35:820-822. Copyright © 2000 by W.B. Saunders Company.

Section snippets

Materials and methods

The patient population consisted of all children less than 3 years of age who underwent a Soave pull-through over a 7-year period. Surgical approach was determined by surgeon preference. Patients were excluded from the study if they had total colon disease or had a previous colostomy, leaving 37 children for analysis. The patients were divided retrospectively into 3 groups: open Soave (OS), transanal Soave with routine laparoscopic visualization (LVS), and transanal Soave with selective

Results

There were 13 patients in the open Soave (OS) group, 9 in the group undergoing a transanal Soave with routine laparoscopic visualization (LVS), and 15 in the transanal Soave with selective laparoscopy or minilaparotomy (TAS) group. Of the 15 children in the latter group, 11 underwent a transanal pull-through alone. Two underwent laparoscopy with biopsy before beginning the perineal dissection, because female gender and a strong family history raised suspicion of long segment disease

Discussion

These data suggest that the 1-stage Soave procedure using a transanal technique is associated with a similar rate of postoperative complications as the same procedure done using an open approach. However, the transanal approach has the advantages of a significantly shorter hospital stay, less need for narcotic analgesics, and lower cost when compared with the open approach.

We have not compared the transanal approach to the various laparoscopic procedures that are becoming increasingly popular.

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Nationwide Outcomes of Immediate Versus Staged Surgery for Newborns with Rectosigmoid Hirschsprung Disease
2023, Journal of Pediatric Surgery
Debate exists on whether patients with Hirschsprung Disease (HD) should undergo immediate resection during their newborn hospitalization or undergo a staged procedure. This study sought to compare postoperative outcomes among newborns receiving immediate versus staged surgery for rectosigmoid HD.
The Nationwide Readmission Database was queried (2016–2018) for newborns with HD who underwent surgical resection during their newborn hospitalization (immediate) versus planned readmission (staged). Those who did not receive rectal biopsy or had long-segment or total colonic HD were excluded. A propensity score-matched analysis (PSMA) of patients receiving either surgery was constructed utilizing >70 comorbidities. Outcomes were analyzed using standard statistical tests.
1,048 newborns with HD were identified (56% immediate vs. 44% staged). Staged resection was associated with higher total hospitalization cost ($56,642 vs. $50,166 immediate), p = 0.014. After PSMA, the staged cohort was more likely to require home healthcare at discharge and experience unplanned readmission (40% vs. 23%). These patients experienced more gastrointestinal complications (40% vs. 22%) on readmission, especially Hirschsprung-associated enterocolitis (35% vs. 20%).
Newborns receiving staged procedures for HD experience higher rates of unplanned readmission complications and incur higher hospitalization costs. This information should be utilized to defray healthcare utilization costs for newborns with HD.
Retrospective Comparative.
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Major stoma related morbidity in young children following stoma formation and closure: A retrospective cohort study
2022, Journal of Pediatric Surgery
Little is known about stoma related morbidity in young children. Therefore, the aim of this study is to assess major morbidity after stoma formation and stoma closure and its associated risk factors.
All consecutive young children (age ≤ three years) who received a stoma between 1998 and 2018 at our tertiary referral center were retrospectively included. The incidence of major stoma related morbidity (Clavien-Dindo grade ≥III) was the primary outcome. This was separately analysed for stoma formation alone, stoma closure alone and all stoma interventions combined. Non-stoma related morbidity was excluded. Risk factors for major morbidity were identified using multivariable logistic regression analysis.
In total 336 young children were included with a median follow-up of 6 (IQR:2–11) years. Of these young children, 5% (n = 17/336) received a jejunostomy, 57% (n = 192/336) an ileostomy, and 38% (n = 127/336) a colostomy. Following stoma formation, 27% (n = 92/336) of the young children experienced major stoma related morbidity, mainly consisting of high output stoma, prolapse and stoma stenosis. The major morbidity rate was 23% (n = 66/292) following stoma closure, most commonly comprising anastomotic leakage/stenosis, incisional hernia and adhesive obstructions. For combined stoma interventions, major stoma related morbidity was 39% (n = 130/336). Ileostomy was independently associated with a higher risk of developing major morbidity following stoma formation (OR:2.5; 95%-CI:1.3–4.7) as well as following closure (OR:2.7; 95%-CI:1.3–5.8).
Major stoma related morbidity is a frequent and severe clinical problem in young children, both after stoma formation and closure. The risk of morbidity should be considered when deliberating a stoma.
Comparison of clinical outcomes after total transanal and laparoscopic assisted endorectal pull-through in patients with rectosigmoid Hirschsprung disease
2022, Journal of Pediatric Surgery
Citation Excerpt :
However, there are concerns that TERPT causes more anal sphincter damage because the exposure of the anal canal is longer and more forceful when the whole operation is performed through the anus [5–7]. The literature comparing bowel function after total transanal and transabdominal ERPT procedures is inconclusive [4,8-11]. Transabdominal ERPT includes operations assisted with both laparoscopy and laparotomy, but these entities are not necessarily identical with respect to preservation of the anal sphincters.
Total transanal (TERPT) and laparoscopic endorectal pull-through (LERPT) are the most common procedures to treat rectosigmoid Hirschsprung's disease (HD). Since few studies have compared the two methods, we aimed to assess clinical outcomes after TERPT and LERPT in this cross-sectional study.
All patients with rectosigmoid HD operated with TERPT and LERPT between 2001 and 2018 were eligible. Peri-operative data were registered from patients’ records, and bowel function was assessed according to the Krickenbeck classification.
91/97 (94%) patients were included; 46 operated with TERPT and 45 with LERPT. Bowel function was assessed in 80 patients at median seven (4–17) years. There was no difference in functional outcome between the procedures. Unplanned procedures under general anesthesia were frequent; 28% after TERPT and 49% after LERPT (p = 0.04). 11% of TERPT and 29% of LERPT patients got botulinum toxin injections (p = 0.03). In the TERPT group, patients operated in the neonatal period had poorer outcome (78%) than those operated later (24%) (p = 0.005). No difference in operative time, length of hospital stay, and rate of early and late complications was found between the procedures.
There was no difference in long-term bowel function in patients with rectosigmoid HD operated with TERPT or LERPT. More LERPT patients had an unplanned procedure under general anesthesia, mostly due to obstructive symptoms.
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Risk factors for short-term complications graded by Clavien-Dindo after transanal endorectal pull-through in patients with Hirschsprung disease
2022, Journal of Pediatric Surgery
Citation Excerpt :
This increased risk after laparotomy-assisted TERPT can be explained by a few factors: first, a selection bias, introduced by the fact that surgeons will more likely opt for laparotomic-assistance in complex patients. Secondly, some surgeons find the mobilization of the splenic flexure more challenging during laparotomic-assistance, potentially resulting in more traction on the anastomosis, compared to colonic mobilization of the splenic flexure via laparoscopy [29,30]. Thirdly, laparotomic-assistance was used more frequently during implementation of the TERPT, when the surgeons were less familiar with the technique, which could have introduced a bias caused by the learning curve of the technique rather than the laparotomic approach that may have led to a higher complication rate [27].
Transanal endorectal pull-through (TERPT) is a common surgical procedure in Hirschsprung disease (HD). Aim of this study was to gain insight in the prevalence and severity of postoperative complications within 30-days after TERPT and to identify patient and perioperative characteristics, associated with the development of short-term postoperative complications.
This study retrospectively analyzed data of children with HD and treated with TERPT in our center between 2005 and 2020. Complications emerging within 30-days after surgery were assessed using Clavien-Dindo (CD). Patient and perioperative characteristic as predictor of a complication were tested using (multivariable) logistic regression analysis.
Twenty-two of 106 (21%) included patients (17 transanal only; 77 laparoscopic-assisted; 12 laparotomy-assisted) developed 35 complications, including two patients (1.8%) that deceased. We suspect postoperative rectal irrigation leading to perforation as cause of death in both patients. Six patients (6%) had a minor (CD<3) and 16 patients (15%) a major (CD≥3) complication. Anastomotic leakage (n = 4, 11%), abdominal abscess (n = 3, 9%) and anastomotic stricture (n = 3,9%) occurred most frequently. Predictive factors for developing a complication were older age at time of surgery (OR 1.03 1.00–1.01, p = 0.041), laparotomy-assisted surgery (OR 12.65, CI 1.712–93.07, p = 0.013) and long-segment HD (OR 4.09 CI 1.09–15.39, p = 0.037).
We found a CD-graded short-term postoperative complication rate of 21% following TERPT, reporting anastomotic complications most frequently. In patients at risk a diverting stoma should be considered. We suspect postoperative rectal irrigation being the cause of two lethal perforations. Therefore, we recommend to place a rectal transanastomotic tube in all patients receiving TERPT.
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The incidence of abdominal surgical site infections after abdominal birth defects surgery in infants: A systematic review with meta-analysis
2021, Journal of Pediatric Surgery
: Surgical site infections (SSI) are a frequent and significant problem understudied in infants operated for abdominal birth defects. Different forms of SSIs exist, namely wound infection, wound dehiscence, anastomotic leakage, post-operative peritonitis and fistula development. These complications can extend hospital stay, surge medical costs and increase mortality. If the incidence was known, it would provide context for clinical decision making and aid future research. Therefore, this review aims to aggregate the available literature on the incidence of different SSIs forms in infants who needed surgery for abdominal birth defects.
: The electronic databases Pubmed, EMBASE, and Cochrane library were searched in February 2020. Studies describing infectious complications in infants (under three years of age) were considered eligible. Primary outcome was the incidence of SSIs in infants. SSIs were categorized in wound infection, wound dehiscence, anastomotic leakage, postoperative peritonitis, and fistula development. Secondary outcome was the incidence of different forms of SSIs depending on the type of birth defect. Meta-analysis was performed pooling reported incidences in total and per birth defect separately.
: 154 studies, representing 11,786 patients were included. The overall pooled percentage of wound infections after abdominal birth defect surgery was 6% (95%-CI:0.05–0.07) ranging from 1% (95% CI:0.00–0.05) for choledochal cyst surgery to 10% (95%-CI:0.06–0.15) after gastroschisis surgery. Wound dehiscence occurred in 4% (95%-CI:0.03–0.07) of the infants, ranging from 1% (95%-CI:0.00–0.03) after surgery for duodenal obstruction to 6% (95%-CI:0.04–0.08) after surgery for gastroschisis. Anastomotic leakage had an overall pooled percentage of 3% (95%-CI:0.02–0.05), ranging from 1% (95%-CI:0.00–0.04) after surgery for duodenal obstruction to 14% (95% CI:0.06–0.27) after colon atresia surgery. Postoperative peritonitis and fistula development could not be specified per birth defect and had an overall pooled percentage of 3% (95%-CI:0.01–0.09) and 2% (95%-CI:0.01–0.04).
: This review has systematically shown that SSIs are common after correction for abdominal birth defects and that the distribution of SSI differs between birth defects.
Laparoscopic-assisted transanal pull-through (LATP) versus complete transanal pull-through (CTP) in the surgical management of Hirschsprung's disease
2016, Journal of Pediatric Surgery
Citation Excerpt :
There was a significant difference in surgery duration between groups, with CTP being completed in less time than LATP (2.6 ± 0.6 h vs. 3.9 ± 1.1 h, p = 0.001). The literature search yielded 423 abstracts, from which 17 articles (12 LATP [12–23], 3 CTP [24–26], and 2 comparative [27,28]) were included (Fig. 1). The main reasons for study exclusion were surgical procedures and outcomes that were not of relevance for this review.
It is unclear whether laparoscopic-assisted transanal pull-through (LATP) or complete transanal pull-through (CTP) is superior for the surgical management of Hirschsprung's disease. We compared outcomes between approaches.
We retrospectively reviewed patients with Hirschsprung's disease who underwent LATP or CTP at our centre between 1995 and 2014. Patients were matched based on age, birth weight, and level of aganglionosis. A systematic literature review and meta-analysis were also performed.
From our data, LATP (n = 24) took significantly longer than CTP (n = 12; 3.9 ± 1.1 vs. 2.6 ± 0.6 h, p = 0.001). There was no difference in length of stay or incidence of postoperative complications. A literature search identified 17 published studies, of which 2 were comparative. Our pooled analysis of comparative studies including our results showed that operative time was significantly longer for the LATP group (OR 1.59, 95% CI 1.21–1.96, p < 0.001). There was no significant difference in major complications (OR 1.75, 95% CI 0.76–4.04, p = 0.19) or length of stay (OR 0.33, 95% CI − 0.41 to 1.08, p = 0.38).
Clinical outcomes are comparable between LATP and CTP. CTP offers shorter operative time without the need for laparoscopic instruments.

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^☆: Address reprint requests to Jacob C. Langer, MD, Chief, Pediatric General Surgery, Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada M5G 1X8.

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One-stage Soave pull-through for Hirschsprung's disease: A comparison of the transanal and open approaches☆

Abstract

Section snippets

Materials and methods

Results

Discussion

J Pediatr Surg

J Pediatr Surg

Semin Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg